Medical-Surgical Nursing: Concepts for Clinical
Judgment
1. A client with heart failure reports increasing shortness of breath when
andflat.
lying Collaborative
What is the nurse’sCare (Ignatavicius, 11th ed.).
best response?
A.Encourage the client to drink more fluids
B. Ask the client to describe sleeping positions used
C. Advise the client to take an extra dose of diuretic
D. Suggest increasing dietary sodium
Correct Answer: B
Rationale: Orthopnea is assessed by asking how many pillows or positions
the client needs to sleep. Fluid and sodium would worsen HF; medication
changes require provider orders.
2. A client with COPD has an SpO₂ of 88% on room air. What action should
the nurse take first?
A.Apply 2 L/min oxygen via nasal cannula
B. Call the provider
C. Place the client flat
D. Administer IV fluids
Correct Answer: A
Rationale: Mild oxygen supplementation improves hypoxemia. COPD clients
often have chronic low O₂ levels; this value requires treatment, not
immediate provider notification.
3. A client with type 1 diabetes is found sweaty and confused. Blood glucose
is 48 mg/dL. What should the nurse give?
A.1 mg glucagon IM
,Medical-Surgical Nursing: Concepts for Clinical
Judgment
B. 15 g rapid-acting carbohydrates
and Collaborative Care (Ignatavicius, 11th ed.).
C. Long-acting insulin
D. Water only
Correct Answer: B
Rationale: Conscious hypoglycemic clients should receive 15 g fast carbs.
Glucagon is for unconscious clients.
4. A client receiving morphine IV reports difficulty breathing. Respiratory rate
is 6/min. What is the priority action?
A.Administer naloxone
B. Give oxygen
C. Notify rapid response
D. Stop other medications
Correct Answer: A
Rationale: Naloxone reverses opioid-induced respiratory depression. Oxygen
may help but does not reverse the cause.
5. A client with pneumonia has crackles and increased sputum production.
Which intervention is most appropriate?
A.Restrict fluids
B. Encourage deep breathing and coughing
C. Give antidiarrheals
D. Limit mobility
, Medical-Surgical Nursing: Concepts for Clinical
Judgment
and Collaborative Care (Ignatavicius, 11th ed.).
Correct Answer: B
Rationale: Deep breathing/coughing improves airway clearance and
ventilation.
6. A postoperative client’s wound edges are separating. What is the priority?
A.Document the finding
B. Push edges together
C. Cover with sterile saline-moistened gauze
D. Apply iodine solution
Correct Answer: C
Rationale: Wound dehiscence requires sterile, moist coverage to prevent
tissue drying and infection.
7. A client with hyperkalemia (K⁺ 6.2) has peaked T waves. What medication
does the nurse expect?
A.Furosemide
B. Calcium gluconate
C. Potassium chloride
D. Lisinopril
Correct Answer: B
Rationale: Calcium gluconate stabilizes cardiac membranes during severe
hyperkalemia.
8. A client with asthma is wheezing and anxious after exercise. What is the
first intervention?
Judgment
1. A client with heart failure reports increasing shortness of breath when
andflat.
lying Collaborative
What is the nurse’sCare (Ignatavicius, 11th ed.).
best response?
A.Encourage the client to drink more fluids
B. Ask the client to describe sleeping positions used
C. Advise the client to take an extra dose of diuretic
D. Suggest increasing dietary sodium
Correct Answer: B
Rationale: Orthopnea is assessed by asking how many pillows or positions
the client needs to sleep. Fluid and sodium would worsen HF; medication
changes require provider orders.
2. A client with COPD has an SpO₂ of 88% on room air. What action should
the nurse take first?
A.Apply 2 L/min oxygen via nasal cannula
B. Call the provider
C. Place the client flat
D. Administer IV fluids
Correct Answer: A
Rationale: Mild oxygen supplementation improves hypoxemia. COPD clients
often have chronic low O₂ levels; this value requires treatment, not
immediate provider notification.
3. A client with type 1 diabetes is found sweaty and confused. Blood glucose
is 48 mg/dL. What should the nurse give?
A.1 mg glucagon IM
,Medical-Surgical Nursing: Concepts for Clinical
Judgment
B. 15 g rapid-acting carbohydrates
and Collaborative Care (Ignatavicius, 11th ed.).
C. Long-acting insulin
D. Water only
Correct Answer: B
Rationale: Conscious hypoglycemic clients should receive 15 g fast carbs.
Glucagon is for unconscious clients.
4. A client receiving morphine IV reports difficulty breathing. Respiratory rate
is 6/min. What is the priority action?
A.Administer naloxone
B. Give oxygen
C. Notify rapid response
D. Stop other medications
Correct Answer: A
Rationale: Naloxone reverses opioid-induced respiratory depression. Oxygen
may help but does not reverse the cause.
5. A client with pneumonia has crackles and increased sputum production.
Which intervention is most appropriate?
A.Restrict fluids
B. Encourage deep breathing and coughing
C. Give antidiarrheals
D. Limit mobility
, Medical-Surgical Nursing: Concepts for Clinical
Judgment
and Collaborative Care (Ignatavicius, 11th ed.).
Correct Answer: B
Rationale: Deep breathing/coughing improves airway clearance and
ventilation.
6. A postoperative client’s wound edges are separating. What is the priority?
A.Document the finding
B. Push edges together
C. Cover with sterile saline-moistened gauze
D. Apply iodine solution
Correct Answer: C
Rationale: Wound dehiscence requires sterile, moist coverage to prevent
tissue drying and infection.
7. A client with hyperkalemia (K⁺ 6.2) has peaked T waves. What medication
does the nurse expect?
A.Furosemide
B. Calcium gluconate
C. Potassium chloride
D. Lisinopril
Correct Answer: B
Rationale: Calcium gluconate stabilizes cardiac membranes during severe
hyperkalemia.
8. A client with asthma is wheezing and anxious after exercise. What is the
first intervention?
